Welcome to the office of Dr. Travis Shaw, MD. We specialize in Facial Plastic and Reconstructive Surgery and Ear Nose Throat.

When I decided to start my own practice, I wanted to make visit to see me a unique experience, unlike any other doctor’s appointment you may have had in the past. I wanted to care for people in a different way. I wanted to use what I learned from my mentor and best friend-my father. Dad was a physician who truly built a relationship with his patients.

I believe that the most important part of the doctor patient interaction is the relationship between you, your family, and your doctor. To that end, I will spend time to learn not only why you came to the office, but learn about you personally. I will do my best to explain things to you on a conversational level- not from the point of view of the doctor telling the patient his or her diagnosis and the surgery he will be performing.

My philosophy in treating people’s appearance is to bring out the inner you with the most natural results possible with the least amount of downtime or discomfort. I will never recommend surgery when an equal result can be obtained via a less invasive option.

You will never feel rushed and your appointments will be long enough to cover the problems that you wish to address that day. I will also provide you with my personal mobile phone so that you can contact me anytime if the need arises.

I designed the office to feel warm and welcoming, not unlike your favorite coffee shop or hangout. The space is open yet cozy, and is designed to make your entire visit as pleasant as possible. There are shared IPADs where you can check email, Facebook, or look at before and after photos.

We are also committed to preserving the environment for our children. Many of the building products and furniture are from sustainable sources. We are committed to a near paperless office by using the latest in technology and electronic medical records, recycling, eco friendly restroom products and beverage service. I donate my unused medical supplies to relief and missions organizations.

You will be personally greeted by our Concierge Laura Beth, who will serve as your personal guide for your entire visit and will assist you in making certain that all of your needs have been met.

I hope to welcome you to my new practice and consider it an honor you have chosen me as your physician.

Travis Shaw, MD

Patient Information
Full Name: ______DOB ______Sex: M / F

Address: ______City:______

State: ______Zip:______

Phone Numbers: (H) ______(Mobile): ______(W)______(Email): ______

Preferred Method Of Contact: (H): (W): (Mobile): (Text): (Email):

SSN ______MARITAL STATUS: (S): (M): (D): (W):

Primary Care Physician ______

Pharmacy ______Location______

Phone______Fax______

Emergency Contact:
Name: ______Relationship______

Phone:______Address: ______City:______State: ______Zip: ______

How did you hear about us? ______

______.

What brings you to see us today?

______.

If you are hoping to make a change in your appearance, what do you hope this change would do for you? (For example, make me feel more confident, make me look more well rested, get me ready for my class reunion etc.)

______.

Do you have now or a history of the following? (please check all that apply):

__ Alcohol/Drugs Anemia__ Asthma

__ Hypertension__ Bleeding Disorder or bruise easily

__ Nasal Allergies__ Nose Bleeds
__ Post-Nasal Drainage__ Sinus Infections

__ Depression Anxiety__ Stroke

__ Scarring__ Ulcers

__ Diabetes__ Difficulty breathing through nose

__Earaches__ Headaches
__ Heart trouble

Please list current medications: ______.

Please list ALL known drug allergies: ______.

Please list previous surgeries or major illnesses with dates ______.

Check any cosmetic treatment you might like to discuss with Dr.Shaw:

ProceduresInjectables

__ Rhinoplasty__ Botox

__ Facelift__ Restylane

__ Neck lift__ Juvederm

__ Blepharoplasty (eyelid lift)__ Radiesse

__ Brow lift

__ Cheek Augmentation

__ Chin Augmentation

__ Otoplasty (ears)

What concerns do you have regarding your skin?(check all that apply)

__Tattoo Removal

__ Brown Spots

__ Wrinkles

__ Acne Scarring

__ Photo-damage

__ Sagging Skin

__ Large Pores

__ Rosacea

What type of skin treatments interest you?(check all that apply)

__ Facial Peels

__ Microdermabrasion

__ Skin Tightening

__ Laser Resurfacing

__ Wrinkle Reduction

Insurance Information

Primary Insurance:______Policy ID:______

Group #:______Group Name______

Policy Holder:______DOB______Sex: M / F SSN______

I hereby authorize the release of medical information to insurance carriers and/or other physicians, and also for benefits to be paid directly Travis Shaw, MD. In the care of a minor, I authorize the filing of insurance claims. I understand that I am responsible for all charges (including non-covered charges) arising for the treatment of the named patient. Should this account become delinquent, I agree to pay all collection and court costs, including attorney’s fees.

Signature ______Date ______